Back Braces: Audit Results

​MAC Region D (Noridian) released audit results from its widespread pre-payment claim review for L0631 and L0637. The results, which covered the time frame from June 2014 through September 2014, show an overall charge denial rate of 98% for spinal orthoses claims.

The report lists three main reasons for denial:

Lack of detailed documentation to support medical necessity

Missing/erroneous Proof of Delivery

No response to Additional Documentation Request

What does this mean for you?

You and your staff must be familiar with the Local Coverage Decisions and Policy Articles, which you can find here: Medicare Coverage Database. The LCD provides detailed information about coverage and documentation requirements.

According to the LCD, a Spinal Orthoses is covered when there is detailed documentation supporting one of the following conditions:

To reduce pain by restricting mobility of the trunk; or

To facilitate healing following an injury to the spine or related soft tissues; or

To facilitate healing following a surgical procedure on the spine or related soft tissue; or

To otherwise support weak spinal muscles and/or a deformed spine.

According to Medicare, the patient’s medical record must have this documentation in order to meet the coverage criteria requirements. The information must be corroborated, meaning it must be present in the prescribing physician’s notes as well.

The LCD, also provides specific information about forms needed to submit a claim. Under the “General Information” section at the end of the LCD, you will find references to Detailed Written Orders (DWOs) and Proof of Delivery (POD.)

When you receive a request from an auditor for additional documentation, you must respond within the timeframe indicated. Failure to respond will result in an automatic denial of the claim, cause you to forfeit your rights to an appeal, and possibly get your practice referred for further auditing. Respond, even if you do not have adequate documentation. Respond, even if the claim will not meet the coverage criteria. Respond.